Medicaid Program Integrity and Current Issues

Federal Entities

Centers for Medicare and Medicaid Services (CMS) – Works to deter, detect, and combat fraud and abuse and take action against those that commit or participate in fraudulent activities. These activities are primarily implemented through the Center for Program Integrity (CPI), which was created to coordinate all program integrity efforts across CMS and other state and federal partners.

Department of Justice (DOJ) – Monitors and enforces federal fraud and abuse laws and prosecutes law violators. Several offices within DOJ are involved in Medicaid program integrity activities, including of the U.S. Attorneys, the Criminal Division, and the Federal Bureau of Investigations (FBI).¹

Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) – Conducts audits, investigations, and evaluations of HHS programs, including Medicaid. It oversees state Medicaid Fraud Control Units (MFCUs), provides resources and education to the health care industry and the public to combat fraud and abuse.²

Government Accountability Office (GAO) – Is a Congressional agency that investigates the federal spending of tax dollars and individual fraud allegations. GAO can audit agency operations and assess whether programs and policies are meeting objectives.³ Other Congressional agencies involved in program integrity activities include the Congressional Oversight Committee, the Medicare Payment Advisory Commission (MedPAC), and the Medicaid and CHIP Payment and Advisory Commission (MACPAC).

State Entities:

State Medicaid Agency – Develops policies and handles the day-to-day operation of Medicaid. In some states, program integrity responsibilities are distributed across agencies, including the Office of the Attorney General and the Office of the State Auditor.⁴ Most program integrity efforts implemented by the states are matched at the standard 50 percent administrative match rate, but some efforts receive higher match rates, including the Medicaid Management Information Systems and survey and certification.

Medicaid Fraud Control Unit (MFCU) – Is an entity of state government that investigates program administration and health care providers, prosecutes (or refers) those defrauding the program, and collects overpayments. They also review cases of abuse and neglect and the misuse of patient personal funds in long-term care facilities.⁵ MFCU costs are matched at a 75 percent rate.